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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206824
Report Date: 10/19/2023
Date Signed: 10/19/2023 10:50:01 AM

Document Has Been Signed on 10/19/2023 10:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MI CASITA DOSFACILITY NUMBER:
107206824
ADMINISTRATOR:JUDIT JAIMEFACILITY TYPE:
735
ADDRESS:296 W. RICHERT AVENUETELEPHONE:
(559) 292-1316
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 3DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Judit JaimeTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) M. Flores arrived unannounced to conduct an annual visit. LPA introduced self, stated the purpose of the visit, and toured the facility with Administrator, Maria Muros. Licensee, Judit Jaime arrived at the facility minutes later. Two clients were present at time of the inspection.

The tour started in the kitchen into the common areas, to the client's bedrooms, and bathrooms. The facility was observed to be at a comfortable temperature of degrees 73 degrees F, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. An adequate supply of perishable and non-perishable food was observed. Cleaning supplies and chemicals stored and locked in the garage. Medications observed kept locked in the kitchen area. All bedrooms were observed to have required furnishings and with adequate lightening. LPA observed three occupant rooms. Bathrooms were properly equipped, and the hot water temperature was tested at 107.9 degrees F. Fire extinguisher was observed with a service date of 10/02/23. Fire drill last completed on 10/02/23. Outside of facility toured and observed to be free of debris. Carbon monoxide and smoke detectors were tested and observed to be operational. Staff and client’s files were reviewed. First Aid checked and fully stocked. LPA conducted interviews with staff and clients.

No deficiencies issued during this inspection. Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by Administrator. Forms requested: LIC308, LIC 309, LIC 400, LIC 402, LIC 500, LIC 610D, LIC 9282, SOC341 training log, and control of property will be submitted by 11/02/23. A copy of this report was provided to the Licensee, whose signature on this form confirms receipt of this report.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Miriam Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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